tci E/M Coding Alert - 2013 Issue 6

Reader Question: When Available, Code Final Dx

Question: I’ve been told that if the treating physician orders a test based on a sign or symptom, we should code the final diagnosis or findings if available instead of the symptom. Where can I locate these guidelines to share with other coders in my office? Ohio Subscriber Answer: You’re exactly right: Code the final diagnosis or results of the test if available rather than the symptom that led to the performance of the test. You’ll find this rule supported by the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.6: “Codes that...

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